Compliance Program

Table of Contents

Compliance Program Introduction

The School has developed a Compliance Program as a comprehensive statement of the responsibilities and obligations of all employees, students and professionals, to understand and adhere to applicable federal and state laws, and to fulfill the program requirements of federal and state health plans. Compliance practices and procedures of the School will be developed and kept current with applicable laws and regulations.

Compliance Program Basic Principles

• Integrity: The School honors integrity as a fundamental value and demonstrates the highest levels of professional conduct in all its dealings. Each individual associated with School must perform his/her personal duties in accordance with these values.

• Compliance with Legal Standards: The School follows all applicable federal and state laws and regulations. Each person associated with the School is charged with the responsibility to learn and understand the legal standards which relate to his/her duties and to follow them accordingly.

• Accurate Billing and Records: The School is committed to maintaining accurate documentation and billing records that reflect services provided. Errors will be assessed and corrected appropriately.

Compliance Program Structure

• Participation: It is the responsibility of each faculty member, staff, student and independent contractor to abide by applicable laws and regulations and support the School’s compliance efforts.

• Responsible Officer: The School has designated the Compliance Director as the individual within the School responsible for overall implementation and operation of the Compliance Program.

• Compliance Committee: The School’s Compliance Oversight Committee will advise and assist the Compliance Director with implementation of the Compliance Program.

• Oversight: The Compliance Director will report at least biannually to the Compliance Oversight Committee on the status of compliance within the School.

• Employee and Vendor Screening: The School shall not contract with, employ or extend privileges to any individual or entity that is excluded from participation or is otherwise ineligible to participate in federal health care programs.

• Education: The School will provide ongoing, effective education and training programs for all faculty, staff and students on Organizational Professionalism and the Compliance Program.

• Auditing and Monitoring: The School will establish procedures for monitoring the effectiveness of the Compliance Program.

• Risk Assessment: The School will conduct ongoing risk assessments and take appropriate steps to reduce the risk of law violation identified through the assessment process.

• Enforcement and Prevention: Individuals violating the standards of this Compliance Program will be subject to progressive discipline, up to and including termination, if warranted. Sanctions will be applied in accordance with relevant staff personnel policies, School policies/procedures and/or faculty code as appropriate.

• Organizational Response: The School will respond to potential violations of the Compliance Program and/or applicable federal and state laws/regulations reported by staff, students, faculty members or others that have questions or concerns regarding School activity.

Employee Participation and Reporting

Approval/Effective Date: 2/27/2008

• Policy: It is the responsibility of every individual to abide by applicable laws and regulations and support the UW School of Dentistry’s compliance efforts. All staff, students and faculty members are required to promptly report their good faith belief of any potential violation of the Compliance Program or applicable law. The School will provide anonymity to the individuals who report concerns to the greatest extent possible under the circumstances. There will be no retaliation in the terms and conditions of employment as a result of such reporting.

• Purpose: The purpose of this policy is to define the individual School staff, student and faculty member responsibilities for assuring ethical business practices and supporting the Compliance Program

• Procedures: Individuals will report their good faith belief of violations of the Compliance Program or applicable laws and regulations via one of the following methods:

- written or oral report to a supervisor or anyone in a School leadership role

- contact the Compliance Director at (206) 543-5331 or tarafao@u.washington.edu or Box 356365

- call the School’s Compliance Hotline at (206) 685-5254

- contact UW Health Sciences Human Resources at (206) 543-9406 or Box 357250

All staff, student and faculty member reports of potential violations will be reviewed at the level determined appropriate. School leaders will ensure that the Compliance Director is immediately informed of any reported concern. Any retaliation for good faith reporting is strictly prohibited.

Responsible Officer

Approval/Effective Date: 2/27/2008

• Policy: The UW School of Dentistry has designated the Compliance Director as the individual within the School responsible for overall implementation and operation of the Compliance Program. The Compliance Director officially reports to the Director of Administration and Finance.

• Purpose: The purpose of this policy is to assign and communicate the responsibility for implementation and operation of the School’s Compliance Program.

• Procedures:

The Compliance Director will be responsible for ensuring that:

1. Practices and procedures are reviewed and updated as necessary.

2. Staff, faculty and vendor screening mechanisms are in place and are operating properly.

3. Independent contractors and agents who furnish services to the School are aware of the requirements of the Compliance Program.

4. Staff, students and faculty are receiving adequate education and training and that such education and training is documented.

5. Internal compliance reviews and monitoring activities are conducted.

6. Staff, student and faculty complaints and other concerns regarding compliance are promptly investigated.

7. Adequate steps are taken to correct any identified problems and prevent the reoccurrence of such problems.

8. External sources of compliance issues are monitored and utilized as prompts for examining School activities.

Compliance Oversight Committee

Approval/Effective Date: 2/27/2008

• Policy: The UW School of Dentistry Compliance Oversight Committee will be established to advise and assist the Compliance Director with implementation of the Compliance Program.

• Purpose: The purpose of this Policy is to assign and communicate the responsibilities of the Compliance Oversight Committee for the Compliance Program at the School.

• Procedures: The Compliance Director will report to the Compliance Oversight Committee biannually. This report will include the results of any recommendations from work conducted during the previous six months, and any other information requested by the Committee. A representative from the Attorney General’s Office will serve as an advisor.

SCHOOL OF DENTISTRY COMPLIANCE OVERSIGHT COMMITTEE

• Members: Compliance Director, Director of Finance and Administration, Executive Director of Development, Alumni Relations and CDE, Director of Clinical Operations, Dean of Dentistry, Associate Deans, Faculty Council Chair, and Department Chairs.

• Meetings: The committee will meet a minimum of biannually.

• Role: The primary role of the Compliance Oversight Committee is to assist the Compliance Director by providing oversight, participating in strategy development, and assessing operational performance of the organization with respect to compliance. In performing this function, the committee will:

• Review concerns and assist with internal risk assessment activities

• Make policy decisions

• Participate in development of the compliance work plan

• Provide executive sponsorship of the work plan initiatives

• Allocate resources for work plan initiatives

• Track resolution of issues

Vendor Screening

Approval/Effective Date: 7/9/2008

• Policy: The UW School of Dentistry shall not contract with any individual or entity excluded from participation or otherwise ineligible to participate in federal health care programs.

Additionally, if an individual or entity with whom the School currently contracts becomes excluded from participation in federal health care programs, the School shall immediately cease contracting with that excluded individual or entity.

• Purpose:The purpose of this policy is to ensure that the School does not receive supplies or services from an individual or entity that has a history of engaging in illegal or improper activities. This policy also seeks to ensure the School does not enter into illegal or improper contract agreements.

• Procedures:

1. This policy applies to the following categories of vendors:

• Suppliers
• Independent contractors
• Agency contract staff
• Consultants

2. The School’s Department Administrators and Program Directors shall be responsible for ensuring that the non-excluded status of prospective vendors and contractors is determined through accessing the OIG List of Excluded Individuals/Entities on the OIG website (www.hhs.gov/oig), and the General Services Administration (GSA) website (www.epls.gov) when making purchases using their procurement Visa card (Procard) or under the direct buy limit of $3,000.

The UW Purchasing Department will be responsible for checking the non-excluded status of the vendors on all requisitions submitted through PAS.

3. Should a vendor or contractor appear on the OIG List of Excluded Individuals/Entities or the GSA website, the School shall not contract with that individual or entity until the issues are resolved and it is clear that the individual or entity is not excluded from participation in federal health care programs.

4. The School’s contracts with vendors and contractors will include language that obligates vendors and contractors to conform to the principles and standards of its compliance program. The following language is to be included in all contracts with individuals or entities:

Federal Exclusion Clause
Vendor represents and warrants that it is not excluded from participation, and is not otherwise ineligible to participate, in a “federal health care program” as defined in 42 U.S.C. § 1320a-7b(f) or in any other government payment program. In the event Vendor is excluded from participation, or becomes otherwise ineligible to participate in any such program during the Term, Vendor will notify the School of Dentistry in writing within three (3) days after such event, and upon the occurrence of such event, whether or not such notice is given to the School of Dentistry, the School of Dentistry reserves the right to immediately cease contracting with that excluded individual or entity.

If Vendor is an Employment Agency, Vendor represents and warrants that its employees are not excluded from participation in a “federal health care program” as defined in 42 U.S.C. § 1320a-7b(f).

Corporate Compliance Plan Clause
The University of Washington, School of Dentistry’s Compliance Program is designed to ensure that the School of Dentistry complies with federal, state, and local laws and regulations. It focuses on the promotion of good corporate citizenship, including a commitment to uphold the highest standard of professional and legal business practices and the prevention of misconduct. Vendor agrees to conduct all business transactions that occur pursuant to this Agreement in accordance with all applicable laws, regulations, and the School of Dentistry compliance policies, and ensure that Vendor officers, employees and agents do the same. Any major compliance violations would be considered a material breach of this contract.

Auditing and Monitoring

Approval/Effective Date: 2/9/2009

Policy: The University of Washington School of Dentistry will conduct audits to monitor the effectiveness of the Compliance Program. Audits will include reviews to verify Compliance Program policies are being followed, as well as reviews of School of Dentistry documentation, billing and coding to verify compliant billing practices.

The School of Dentistry will devote such resources as are reasonably necessary to ensure that the audits are (1) adequately staffed; (2) performed by persons with appropriate knowledge and experience to conduct the audits; (3) utilizing tools and protocols which are periodically updated to reflect changes in applicable laws and regulations. Monitoring activities will include compliance audits and program reviews:

Compliance Audits; The University of Washington School of Dentistry will conduct periodic compliance audits by auditors who have expertise in Federal and state healthcare statutes, regulations, and Federal health care program requirements.

Program Reviews; The University of Washington School of Dentistry will annually assess whether or not Compliance Program elements have been satisfied.

Purpose: The purpose of this policy is to ensure the effectiveness of the Compliance Program by establishing audit procedures. Procedures:

1. The Compliance Director is responsible for maintaining the comprehensive Compliance Audit Plan for the School of Dentistry, to include audits/reviews conducted by the Compliance Director or designee, outside consultants and individual departments. The Compliance Director will oversee audits conducted by Departments.

2. The Compliance Director will verify completion of audits/reviews on the Compliance Audit Plan and any corrective action measures arising from them.

3. Following completion of a department/clinic audit, auditors/reviewers and Compliance Director will meet with the appropriate department management (and others as requested) to review and discuss the results of the audit prior to finalizing the summary report. In advance of the meeting, a copy of the results will be distributed to the attendees. The purpose of the meeting is twofold:

• Give the department the opportunity to provide explanation or additional documentation to clarify any concerns that have been identified in the audit.

• Create a departmental corrective action plan to address any adverse findings. This plan will identify the deliverables and the due date and individual responsible for each. If the plan requires additional time to produce, the meeting participants will agree on a due date for the department to submit the corrective action plan to the Compliance Director.

4. The Compliance Director will distribute the final summary report, including any necessary corrective action plan(s). At a minimum, the final summary report will be sent to the following individuals:

• Manager of the department/clinic audited/reviewed

• Department administrator

• Department chair

• Associate Dean of Clinical Services

5. The Compliance Director will monitor for completion of the departmental corrective action plan. Once the corrective action plan is completed, the Compliance Director or designee will perform a follow-up audit to ensure the effectiveness of actions taken.

6. In all cases, Departments will initiate resolution actions within 14 days of receiving adverse finding information.

7. The Compliance Director will maintain a tracking system wherein corrective action plans and follow-up verification are monitored for completion.

8. The Compliance Director will routinely report to the Compliance Oversight Committee on the results of audits and the status of corrective actions.

Risk Assessment

Approval/Effective Date: 4/6/2009

• Policy: The University of Washington School of Dentistry will conduct ongoing risk assessments and take appropriate steps to reduce the risk of law violation identified through the assessment process.

• Purpose: The purpose of this policy is to set forth the procedures that will be followed to ensure that the School of Dentistry Compliance Program and operational practices are evaluated and modified as necessary in response to the risk for potential legal violations.

• Procedures:

1. The Compliance and Privacy Director monitors changes in laws and regulations through regular review of governmental websites, newsletters and other communication channels.

2. The Compliance and Privacy Director monitors areas of risk identified by the Federal government through regular review of enforcement activities, the annual OIG Work Plan, OIG Compliance Guidance, advisory bulletins, fraud alerts, and the information sources listed in item #1.

3. When an issue that has the potential to affect the School of Dentistry is identified, the Compliance and Privacy Director prepares an assessment of the nature and seriousness of potential violations of law and the likelihood that such violations may occur based on the nature of School of Dentistry business or prior history of the organization.

4. Risk assessments are reviewed and discussed at the Compliance Oversight Committee meetings, where any necessary response actions are approved, prioritized and added to the Compliance Work Plan.

5. Risk assessments are documented in the Compliance Oversight Committee meeting minutes.

Workforce Screening

Approval/Effective Date: 07/22/2009

Policy: The UW School of Dentistry shall not contract with, employ or extend privileges to any prospective employee, dentist or health professional excluded from participation or otherwise ineligible to participate in federal health care programs.

If an individual whom the School currently employs or credentials becomes excluded from participation in federal health care programs, the School must immediately remove the individual from direct or indirect responsibility for or involvement in any federally-funded health care program. The individual may be terminated, consistent with the terms and conditions of employment. The School will make reasonable inquiry into other criminal offenses of prospective workforce members.

Purpose: The purpose of this policy is to ensure that individuals acting on behalf of the School do not have a history of engaging in illegal or improper activities.

Procedures:

1. The Office of Medical Staff Appointments verifies the non-excluded status of dentists and other health professionals with medical staff appointments by accessing the Healthcare Integrity and Protection Data Bank (the “HIPDB”).

2. Upon employment, School of Dentistry Administrators or their designees verify the non-excluded status of prospective employees by accessing the Department of Health and Human Services Office of Inspector General (OIG) List of Excluded Individuals/Entities on the OIG website (www.hhs.gov/oig), and the General Services Administration (GSA) website (www.epls.gov). School Administrators or their designees also verify the non-excluded status of graduate students upon matriculation and on an annual basis by accessing the OIG and GSA websites described above.

3. The Office of Student Life and Admissions verifies the non-excluded status of all pre-doctoral Dentistry students upon matriculation and on an annual basis by accessing the Department of Health and Human Services Office of Inspector General (OIG) List of Excluded Individuals/Entities on the OIG website and the General Services Administration (GSA) website.

4. Medical Centers Human Resources verifies the non-excluded status of all University of Washington employees on an annual basis by accessing the Department of Health and Human Services Office of Inspector General (OIG) List of Excluded Individuals/Entities on the OIG website (www.hhs.gov/oig), and the General Services Administration (GSA) website (www.epls.gov).

5. Should an employee, dentist or other health professional appear on the OIG List of Excluded Individuals/Entities, the GSA website, or the HIPDB, the School may not employ or extend privileges to that individual until the issues are resolved and it is clear that the individual is not excluded from participation in federal health care programs.

6. Current employees, dentists or other health professionals whose names appear on the OIG List of Excluded Individuals/Entities, the GSA website, or the HIPDB will be removed from direct or indirect responsibility for or involvement in any federally-funded health care program.

7. Conviction/criminal history information will be obtained for all prospective employees and faculty, in accordance with Washington State law and University policy